This month, there are several topics that are "hot". Among them, Medicaid expansion in Iowa and Medical Malpractice reform. The IMS has been hard at work on these topics.

I'll summarize them here, giving both the IMS perspective and other views and comments. I'll label my opinion as separate from IMS. As one would expect, profound agreement is rarely found in a group, as each person brings their diverse opinions to the table.================Medicaid expansion in Iowa is a complex issue; it's easy only from the viewpoint of the person speaking. Finding the common ground is more difficult.

There are several ways to consider this; what follows is my opinion, not necessarily IMS'.

Our current state of affairs (without expansion of Medicaid coverage to those @ <138% of federal poverty; $15.4K) is a few doctors accept patients on Medicaid into their private offices, some coverage is through FQHC (Siouxland Community Health (slandchc.org), Union County Health Foundation (allpointshealth.com), Sioux Center Promise Clinic (greatersiouxchc.org) and much is through the local ER's. Each of these is problematic.*Private offices can't be expected to shoulder a huge part of the uninsured without understanding that, if enough care is given away, the office will close, making no care available for anyone.*FQHC (Federally Qualified Health Centers) can shoulder only so much of the burden, and they often require some copay.*ERs' are the default safety net. When treating uninsured, the hospital doesn't get paid and so must pass on these costs to the insured or, through taxes, to the taxpayer. In addition, where the physician in the ER is not an employee, the situation is directly analogous to the private office. If an employee, his/her pay is decreased. And, in Iowa, if you seen by a physician in an ER, it is about 80% likely that an FP touched you, not an EP.(escholarship.org/uc/item/1q06z6c1,iowaacep.org/Portals/41/docs/ChapterGrant_FinalReport_Iowa.pdf) Thus, we hurt the very group of physicians we are supposed to be raising up!

Added to our current state of affairs is Iowa Cares. This is a quasi insurance that provides for care only at 2 facilities, Des Moines' Broadlawns and U of Iowa. For us in NW IA, this is irrelevant and a bit cynical. While well intended initially, the presence of a program like this permits the public to not face the lack of health care provided to the poor.

On the economic side, from a non-economist's view, it seems pretty easy. Under the ACA, Iowans will pay into a pool with the other 49 states; this is called taxes. Iowans will pay into this pool regardless of expansion. Having paid into the pool, we can walk away or drink. Walk away makes the most sense if you agree with how Iowa is treated under current Medicare; where we subvend the prolifgate spending of other states. Iowans' money is going to improve employment and standards of living elsewhere.

There is another way. Having paid into the pool, Iowans can draw from it. When mature, Iowa will draw 90% of its funding from the common pool, 10% from State coffers (state taxes.) (Forget worrying about future changes; the present is complex enough!) Having drawn the 10% from within state borders, 100% would be paid out within State borders, if properly structured. Taxed at a 10% rate, this would replace into State coffers the same amount as extracted. (This is simplified, but assumptions taken on either side tend to regress to the mean. Money turns over 5 - 8 times locally. >60% of hospital expense is payroll. There is leakage from the tech side, but that can change.) Remember, either way, you'll be paying in.